The 4 youth by youth HIV self-testing crowdsourcing contest: A qualitative evaluation

Introduction Crowdsourcing, a participatory approach to solicit ideas from a large group of diverse individuals, provides an opportunity to nurture youth participation in HIV self-testing service design. The objective of this study was to describe the responses to a crowdsourcing contest aimed at soliciting ideas on how to promote HIV self-testing (HIVST) among young people in Nigeria. Methods The “4 Youth by Youth” HIV Self-Testing Crowdsourcing contest was an online and off-line contest that asked Nigerian youth (10–24 years old) for ideas in response to the following: How might we promote HIVST among young people in Nigeria? All data were collected and analyzed between October 2018, and June 2019. Ideas and perceptions generated from the crowdsourcing contest were qualitatively analyzed using thematic content analysis. Specifically, four reviewers analyzed whether the ideas generated were desirable (appealing to young people), feasible (easy to implement) and impactful (will significantly influence HIVST uptake among young people). Results A total of 903 entries were received in response to the contest prompt. Participants submitted entries in various forms: online form (39.7%), offline Dropbox (44.6%), email (6.1%) and WhatsApp (9.7%). Of the total entries, 85% (n = 769/903) entries were eligible and were scored as having either high, moderate or low level of feasibility, impact and desirability, on a 3-point Likert scale. A significant portion of the entries were given a score of 3 for feasibility (4.9%), desirability (7.1%), impact (3.0%) or a total overall score of 7 or more (8.2%). The three main themes that emerged from the entries include:1) Peer-to-peer distribution and leveraging on existing infrastructures 2) Youth-Oriented Branding of the HIVST Kit 3) Mobile platforms and social media technology. Conclusion The “4 Youth by Youth” Self-Testing contest engaged a broad audience of young people to generate ideas and perspectives on how to promote HIVST. This process informed the development of youth innovated implementation strategies to increase uptake of HIVST among adolescents and youth at risk for HIV.


Introduction
HIV incidence remains high among adolescents and young people in Africa, thus underscoring the importance of interventions to prevent HIV among young people. Crowdsourcing provides an opportunity to nurture youth participation in HIV self-testing service design. The objective of this study was to describe the responses to a crowdsourcing contest aimed at soliciting ideas on how to promote HIV self-testing (HIVST) among young people in Nigeria.Methods The "4 Youth by Youth" HIV Self-Testing Crowdsourcing contest was an open crowdsourcing contest (both online and off-line) that asked Nigerian youth (10-24 years old) for ideas in response to the following: How might we promote HIVST among young people in Nigeria? All data were collected and analyzed between October 2018, and June 2019. Ideas and perceptions generated from the crowdsourcing contest were qualitatively analyzed using thematic content analysis. Specifically, four reviewers analyzed whether the ideas generated were desirable (appealing to young people), feasible (easy to implement) and impactful (will significantly influence HIVST uptake among young people).Results A total of 903 entries were submitted to the contest. Participants submitted entries in various forms: online form (39.7%), offline Dropbox (44.6%), email (6.1%) or WhatsApp (9.7%). Of the total entries, 769 entries were eligible and were scored as having either high, moderate or low level of feasibility, impact and desirability, on a 3-point Likert scale. A significant portion of the entries were given a score of 3 for feasibility (4.9%), desirability (7.1%), impact (3.0%) or a total overall score of 7 or more (8.2%). The three main themes that emerged from the entries include:1) Peer-to-peer distribution and leveraging on existing infrastructures 2) Youth-Oriented Branding of the HIVST Kit 3) Mobile platforms and social media technology.Conclusion The "4 Youth by Youth" Self-Testing contest engaged a broad audience of young people to generate ideas and perspectives on how to promote HIVST. This process informed the development of youth innovated implementation strategies to increase uptake of HIVST among adolescents and youth at risk for HIV.  HIV self-testing service design. The objective of this study was to describe the 49 responses to a crowdsourcing contest aimed at soliciting ideas on how to promote HIV 50 self-testing (HIVST) among young people in Nigeria. 51 52 Methods: The "4 Youth by Youth" HIV Self-Testing Crowdsourcing contest was an 53 online and off-line contest that asked Nigerian youth (10-24 years old) for ideas in 54 response to the following: How might we promote HIVST among young people in 55 Nigeria? All data were collected and analyzed between October 2018, and June 2019. 56 Ideas and perceptions generated from the crowdsourcing contest were qualitatively 57 analyzed using thematic content analysis. Specifically, four reviewers analyzed whether 58 the ideas generated were desirable (appealing to young people), feasible (easy to 59 implement) and impactful (will significantly influence HIVST uptake among young 60 people). 61 62 Results: A total of 903 entries were submitted to the contest. Participants submitted 63 entries in various forms: online form (39.7%), offline Dropbox (44.6%), email (6.1%) or 64 WhatsApp (9.7%). Of the total entries, 769 entries were eligible and were scored as 65 having either high, moderate or low level of feasibility, impact and desirability, on a 3-66 point Likert scale. A significant portion of the entries were given a score of 3 for 67 feasibility (4.9%), desirability (7.1%), impact (3.0%) or a total overall score of 7 or more 68  Specifically, we focused on Nigerian youth ages 10-24 as potential end-users of HIVST 130 as they remain at increased risk for acquiring HIV, yet the majority are unaware of their 131 status. The purpose of this study is to examine youth responses to an HIVST 132 crowdsourcing contest in Nigeria to promote the uptake of HIVST among young people.

Evaluate ideas 178
The initial selection criteria were that participants had to be between the ages of 10 to 179 24 years, and residing in Nigeria, and their ideas had to describe novel strategies to 180 promote uptake of HIVST among Nigerian youth in English. The eligible entries were 181 further reviewed by four contest organizers and rated based on their feasibility, 182 desirability and impact using a 3-point scale (3=high, 2=moderate or 1=low level), which 183 was adapted from the human-centered, design thinking framework [38]. Two members of the research team initially screened all 903 entries received for duplicates and 185 relevance to the scope of the contest. Entries that could not be scored for any of the 186 three criteria, entries from participants above 25 years, and those that were duplicate 187 submissions were excluded from further analysis. Subsequently, each of the four 188 reviewers independently rated the ideas submitted using the following three criteria: 1) 189 desirability-Is the idea appealing to youth? Does the idea meet the needs (low-cost, 190 accessible, confidential) of young people?; 2) feasibility-Can the idea be easy to 191 implement? Are the resources available to execute the idea?; and 3) Impact-Will the 192 idea significantly influence young people to self-test for HIV? Is the idea able to reach 193 young people in Nigeria when available? Finally, the scores for the three criteria were 194 summed to generate an overall score for each of the entries with a range of 3 to 9. 195 Entries that received an overall score greater than 7 (pre-specified by the advisory

Data analysis and coding 202
After the contest was completed, each participant entry was deidentified and transcribed 203 to allow for a thematic analysis of data [39]. Summary statistics were used to describe 204 participant demographics and crowdsourcing metrics. Entries were reread by 4 trained 205 qualitative researchers and content analysis was performed to code the data and 206 identify similar patterns or categories. A modifiable coding sheet informed by the data 207 was used to code the entries to identify commonalities and differences between the 208 data. Following initial coding, the entries were reread to refine the coding sheet and a 209 sample of transcripts were provided to two of the researchers who independently WhatsApp=78; Email=47), and the remaining 40% (n=353) submitted a paper version of 222 the application. Most the entries were submitted by individuals residing in Lagos state 223 (91%, n=819). However, we shortlisted the entries based on pre-specified criteria. Of 224 the 134 entries (15%) that were not eligible, 6 of those were duplicate entries, 113 were 225 entries that could not be scored and 15 were entrants who were older than 24 years. In 226 total, we found 769 eligible, non-duplicated entries submitted by 769 applicants. Among 227 these youth, 33.6% were less than 14 years, 44.2% were between the ages of 15 to 19 228 years, and 22.2% were between the ages of 20 to 24 years old. Approximately half of 229 the participants were females (51.2%) and more than half had obtained a primary education (52.6%), whereas, 47.4% of the participants had obtained a secondary 231 education or higher. 232

233
Regarding the content of the 769 entries, the average word count of the written entries 234 was 180 words and the average video length for entries was 2.14 minutes (range: 0.3 -235 5.34 minutes). Fifty-four entries used a combination of text with images (refer to Fig 1), 236 6 entries were a combination of texts and videos, and the remaining entries were 237 completely in text format. Thirty five percent provided an overview on HIV and risk 238 factors among young people, while 61% addressed existing barriers to HIV self-testing. 239 The mean overall score of all eligible entries was 4.0/9.0 (standard deviation = 1.5) with 240 8.2% receiving a high overall score (7-9). On individual criteria, a high score of 3 was 241 received by about 7.2% of the entries rated on desirability, 4.9% rated on feasibility, and 242 3.0% rated on impact. The most relevant themes for promotion of HIVST that emerged 243 from the open challenges are presented below and in Table 1. 244 245 Peer-to-peer distribution and existing infrastructures "… introducing the HIV self-testing kit to them, train them on how to use, and encourage each of them to have group of ten and train them at community level for a certain period while each of those peers would also have their group to be train at the end of their passing out…" "Five to ten students will be selected from each school for training including their mentors on contents that will include: Meaning of AIDS, HIV and STIs, what is HIV Testing, …Communication Skills…, abstinence and other life sustenance skills…" "... Would engage youth as Peer Educators, counsellors and caregivers charged with the responsibility of client follow up, marketing and sales of test kits…" "HIV self-testing can be improved among youth through collaborating with organizations responsible for community-based program as well as workshop to enable youth participate and be enlightened about the self-testing method." "Using outreach programs including communitybased programs, that are already in place to connect with the young people in Nigeria..." Desirable ideas for HIVST Delivery (Is the idea appealing to youth? Does the idea meet the needs (low-cost, accessible, confidential) of young people?) Youth Branding of the HIVST Kit "Would package the test kit in sky blue color nylon pack sealed; hence can be folded easily for easy carriage. Make it the size of a medium Bible; with each pack containing the test kit, a direction on how to use and read results…" "Packaged in portable easy to keep 6-inch by 6inch purple and pink thick nylon or foil containers with the picture of a confident cheerful, relaxed and good-looking young person on it..." "it should be packaged in a pink or purple color pack; the size of 2 Gold circle packs of condoms, with information leaflet stating the step by step use and how to read result. It must come with human (young persons) pictures and carefully folded into each pack with background information about the test kit, basic facts about HIV & AIDS and a directory of Youth Friendly Organizations providing ART services with contact phone lines (hot lines) for confidential referral and treatment services. Information on the leaflet will come in Yoruba, Igbo, Hausa, English and Pidgin English languages" "It should cost between N500 to N1000…" Impactful ideas for HIVST delivery (Will the idea significantly influence young people to self-test for HIV? Is the idea able to reach young people in Nigeria when available?) Mobile platforms and social media technology "…awareness can be created using short videos on how HIV self-testing can be done and this will be sent to different social media platform including Facebook, Twitter, Instagram, WhatsApp and so on. Meanwhile we can attach a reward (which could be in form of data or call unit) for those with highest videos shared or highest viewer or possibly the highest videos liked." "To start any movement, a short and effective hashtag like '#shaku-test' could be used, which can be unconsciously picked up by the average Nigerian youth. It can be made more effective by using funny memes and tagging Nigerian celebs that are inclined to advocacy." "..a mobile interactive application will be created to guide the user on how to carry out the test and support the user where the result is positive" "Virabust proposes a mobile health communication platform (app) for HIV and other STI Self-Test procedures with incentivized and multi-model (visual, text, auditory) channels to promote self-testing among young people in Nigeria." 248

Peer-to-peer distribution and harnessing existing infrastructures 249
Peer-to-peer distribution were described as potentially feasible strategies for mobilizing 250 HIVST delivery among young Nigerians. Participant entries suggested that supportive 251 interactions among peers as well as discussions by young people with their peers may 252 promote and increase awareness on proper use of the HIVST kits. Youth also provided 253 ideas on using peer educators as role models or brand ambassadors for HIV self-testing 254 kits. They suggested that these peer educators can also train other young people using 255 the train-the-trainer model so that other youth could become engaged in the delivery of community centers serving young people were also described by participant entries, as 258 existing infrastructures that could be potentially harnessed to promote HIVST delivery. 259 Participants suggested that mobilization activities should focus on these infrastructures 260 since they already interact with large numbers of young people. Example of feasible 261 themes are included in Table 1. 262 263

Youth-Oriented Branding of the HIVST Kit 264
Overall, participant entries included several suggestions for making HIVST more 265 appealing to young Nigerians. This included repackaging existing HIVST products with 266 colors, taglines, designs, and animations that are youth-friendly (75%). A significant 267 number of entries highlighted making the package smaller and more flexible in order to 268 be discreet. Additionally, several entries suggested providing instructions translated in 269 the three most common Nigerian languages (Igbo, Hausa and Yoruba) to enhance 270 appeal to a diverse segment of youth in Nigeria. Notably, several participant entries 271 described a comprehensive approach to HIVST promotion, incorporating different 272 youth-friendly health products, including personal hygiene products such as grooming 273 kits for men and sanitary pads for females to enhance HIVST appeal. Finally, participant 274 entries emphasized the need for HIVST products targeting youth to be low cost with 275 price ranging from 500-1000 naira ($1.38-$2.78) so as to be affordable to Nigerian 276 youth. Example of desirable themes are included in Table 1. 277

Mobile platforms and social media technology 279
With the high penetration of mobile technology and social media use among young 280 people in Nigeria, 11.3% of entries suggested the use of these technologies to promote 281 HIVST among youth in Nigeria. Some of the entries suggested using local context-282 specific taglines and hashtags to increase demand for HIVST on social media. Similar 283 to popular viral campaigns on social media, participants' entries suggested that these 284 locally derived taglines or hashtags are common in Nigeria and can be used as tools to 285 create awareness and mobilize HIVST delivery to young Nigerians. Entries also 286 suggested recruiting local celebrities to endorse these hashtags to generate demand 287 not only among these celebrities but also among their young fans. Notably, some 288 entries suggested that mobile and social media platforms can be used to carry out 289 nationwide campaigns in the form of contests on how to promote HIVST, similar to the 290 one organized by 4YBY platform. Participants suggested that contests are an impactful 291 approach to reach and engage young people and can be used as a strategy to not only 292 mobilize youth, but also to encourage engagement and subsequent uptake of HIVST. 293 Example of impactful themes are included in Table 1 First, we successfully crowdsourced for ideas for promoting HIVST and engaged a large 304 audience of 769 young people. This contest generated a much higher participation rate 305 when compared to other crowdsourcing challenges and is one of the largest 306 crowdsourcing contest for health. [28,37,40] Notably, the contest engaged young men 307 and women across Nigeria, both online and offline. More than 66% of the participants 308 were 15 years or older, while 33.6% were younger than 15 years of age. Although few 309 social media or online interventions are traditionally targeted at young people in low-or 310 middle-income countries [41], this study illustrates the potential to access multiple youth 311 age groups through an open challenge contest using existing online platforms. Given 312 that internet bandwidth is rapidly increasing across many African regions, a 313 crowdsourcing approach may be able to reach farther into rural and other under-served 314 areas. 315 316 Second, we identified themes that may be useful for future public health campaigns or 317 initiatives that seek to raise awareness and scale up HIVST uptake among young 318 people in Nigeria. Many of the entries submitted in this contest proposed conventional 319 approaches (for example, using outreach programs including community-based 320 programs, that are already in place to connect with the young people in Nigeria) that are 321 considered feasible to implement. However, few proposed unconventional but impactful 322 and desirable ideas (for example, creating awareness using short videos on how to use a HIVST kit, which will then be shared on several social media platforms and viewers 324 will automatically earn bonus points that can be used to gain rewards) that could 325 potentially draw attention to HIVST and make them more noticeable to youth 326 populations. To our knowledge, this study is the first to elicit ideas from young people 327 about how to make HIVST more youth-friendly and our findings could be used to not 328 only create models for HIVST distribution that are desirable to young people, but also 329 kits that would influence uptake of HIVST, thus increasing the proportion of youth who 330 are aware of their HIV status and facilitating appropriate health-seeking behaviors. 331 332 Third, an important finding from our contest was the meaningful engagement of young 333 people in generating input, images, and outreach strategies that may potentially 334 enhance demand for HIVST among young people in Nigeria. Findings generated youth 335 ideas on potential mobilization efforts, including where these activities should focus, 336 who should carry out these activities and what additional services or support tools may 337 be incorporated to increase demand and uptake of HIVST among Nigerian youth. 338 Engaging young people to identify solutions on how to promote HIV self-testing is 339 important in developing HIVST campaigns and distribution messages that will resonate 340 with young people. It ensures that crucial youth perspectives, cultural and linguistic 341 appropriateness are incorporated in mobilization strategies to promote HIVST uptake 342 among youth in Nigeria. Overall, the entries received from the open challenge contests 343 give voice to young people's lived experiences in Nigeria and could serve as an 344 important step with effectively reaching and engaging young people with HIVST, 345 particularly those who may not otherwise test using conventional strategies. 346

Disclaimer 393
The comments and views of the authors do not necessarily represent the views of the 394 Click here to download Figure Fig1.docx